Carol Holtz
Ibrahim Elsawy
“It’s immoral that people in Africa die like flies of diseases that no one dies of in the United States. And the more disease there is, the more political unrest there will be, leading to more Darfurs.”
Former President Bill Clinton
OBJECTIVES
After completing this chapter, the reader will be able to:
1. Discuss family planning, infertility, abortion, and sterilization practices in Egypt, China, India, and South Africa.
2. Explain how communism affects health and health care in China.
3. Discuss women’s rights issues in South Africa.
4. Compare the health and healthcare systems of Egypt, China, India, and South Africa.
INTRODUCTION
This chapter addresses the health conditions of four developing countries: Egypt, China, India, and South Africa. These countries were selected for examination because they differ in culture, economics, politics, geographic regions, and types of health care and health issues.
EGYPT
Background
Egypt (the Arab Republic of Egypt) is located in the far northeastern part of the African continent, bordered on the north by the Mediterranean Sea, on the east by the Red Sea, on the west by Libya, on the south by Sudan, and on the northeast by the Gaza Strip and Israel. Egypt is traversed by the Suez Canal, which is located between its Asian and African territories. The country’s total land area is 1,002,450 square kilometers. Most of Egypt is located in Africa, but part of its land, the Sinai Peninsula, is located in Asia. The majority of its population of approximately 83 million people lives on the banks of the Nile River or on the coasts of the Mediterranean Sea, the Red Sea, and the Suez Canal. The largest defined landmass within Egypt is the Sahara Desert, which is very sparsely populated. The largest cities include Cairo (the capital), Alexandria, and other cities in the Nile Delta. Ninety-eight percent of the Egyptian population lives on just 4% of the country’s land (Arab Republic of Egypt, Ministry of Foreign Affairs, 2010).
Most of Egypt’s rainfall occurs during the winter months, with only 0.1 to 0.2 inches of precipitation falling each year. Before the construction of the Aswan Dam, the Nile River flooded annually, producing good soils and good harvests in its floodplains.
Arabic is the official language; English and French are the most commonly used foreign languages. The majority ethnic groups are Egyptian, Bedouin Arab, and Nubian. Education is compulsory for children aged 6–15 years, and the literacy rate is 58% (“About Egypt,” 2010).
Egypt has a distinguished cultural heritage, accumulated over the thousands of years of its history. Each of the Egyptian successive civilizations (Pharaonic, Greco-Roman, Coptic, and Islamic) contributed to the areas of philosophy, literature, and the arts. Because of its long-held ties with Europe, Egypt has been a cultural pioneer in the modern Arab world. In 2002, with the support of the United Nations Educational, Scientific and Cultural Organization (UNESCO), the new Bibliotheca Alexandrina was inaugurated. This world-recognized special historical site is located in Alexandria. The goal of the reconstruction of the ancient Library of Alexandria was to revive the legacy of this universal center for science and knowledge (“About Egypt,” 2010).
In terms of religion, the Egyptian population consists of 94% Muslims and 6% Christians. The two main Islamic institutions in Egypt are the oldest and the most important Islamic institutions in the country:
■ Al-Azhar, which was built by the Fatimids to spread the Shiite sect in North Africa. Later Salah El-Din converted it to Sunni University, which became one of the main pillars of Sunni Islam in the world.
■ Dar el Eftaa, founded in 1895 and headed by the Grand Mufti of Egypt.
The Coptic Orthodox Church, one of the oldest Christian churches in the world, and the Roman Orthodox Church of the Arab Republic of Egypt are located in Alexandria (Arab Republic of Egypt, Ministry of Foreign Affairs, 2010).
Economy
Table 3-1 presents statistics on Egypt’s current economy.
TABLE 3-1 Egypt’s Economy
GDP
$218.91 billion
GDP growth
5.2%/year
Inflation, GDP deflator
10.1%/year
Agriculture, value added
10% of GDP
Industry, value added
29% of GDP
Services and other revenue sources, value added
61% of GDP
Exports of goods and services
21% of GDP
Imports of goods and services
28% of GDP
Gross capital formation
19% of GDP
Source: World Bank, 2010.
Health
Table 3-2 presents population health statistics for Egypt.
Healthcare Systems
The majority of Egyptians have access to health care for basic health services, managed by the Ministry of Health and Population (MOHP), the Health Insurance Organization (HIO), private health practitioners, and nongovernmental organizations (NGOs). The HIO covers 45% of the population, and there is a growing and unregulated private healthcare sector. Pharmaceuticals account for nearly one-third of all health-care costs (World Health Organization [WHO], 2011).
TABLE 3-2 Egypt’s Population Health Statistics, 2011
Birth rate
28.9 per 1000
Underweight children
7.5%
Population younger than age 15 years
31.7%
Population 65 years or older
3.7%
Total births per woman
3
Adult literacy rate (among persons 15 years or older)
71%
Population with sustainable access to improved water sources
94%
Population with sustainable access to improved sanitation
94%
Smoking rate of adults
19%
Total government expenditure per capita on health
$124
Total government expenditure on health as a percentage of GDP
6.4%
Out-of-pocket expenditure on health per capita
58.7%
Human Resources (per 10,000)
Physicians
28.3
Dentists
4.2
Pharmacists
16.7
Nurses and midwives
35.2
Hospital beds
17.3
Primary healthcare units and centers
0.7
Primary Health Care (per 100)
Population with access to healthcare services
88
Contraception prevalence
57.6
Prenatal care
52
Births attended by skilled personnel
84
Health Status
Life expectancy
72.3 years
Infant mortality rate (per 1000 live births)
17
Under-five mortality rate
21.8 per 1000
Maternal mortality rate
55 per 100,000
Probability of not reaching 40 years of age
10.3%
Smokin revalenc amon ales 1 ears or older
40%
Source: WHO, 2011.
Communicable Diseases
Within the last decade there has been a huge decline in deaths from communicable diseases in Egypt, largely due to the high rate of vaccinations for preventable diseases. Hepatitis B and C continue to be problems, however. Schistosomiasis (a parasitic disease caused by flatworms), hepatitis C (affecting 9.8% of the general population), and tuberculosis are the top three infectious diseases found in Egypt today (WHO, 2011).
A study conducted in Egypt and supported by USAID to prevent typhoid fever in rural communities used the intervention of hand washing with soap. Studies indicate that 9000 to 42,000 cases of typhoid are reported in this country each year. Typhoid fever is transmitted by the fecal–oral route, so it is appropriate to build prevention strategies against this infection—yet only 40% of all households in Egypt had soap and water available for hand washing at the time the intervention was undertaken. The scarcity of water and problems with waste disposal are related issues for hand washing. As part of the intervention, proper hand washing techniques were taught and general education of disease transmission was performed. Results indicated improvement in hand washing rates in the rural Fayoum region of Egypt (Lohinivak, El-Sayeed, & Talaat, 2008).
Maternal and Infant Health
Despite health clinics that are accessible to the general public, maternal and infant mortality rates in Egypt are high, with an infant mortality rate of 17 deaths per 1000 live births and a maternal mortality rate of 55 deaths per 1000 live births. In addition, the 21.8 per 1000 death rate for children younger than age five is considered high. These rates reflect exceptionally high mortality rates among women and children in rural Upper Egypt. Child survival initiatives, such as cord care, delivery instrument antisepsis, and infant warming have reduced the rate of mortality of children younger than five years.
As is true in most developing countries, most births in Egypt take place in the home. A major contributing factor to maternal and infant morbidity and mortality is unhygienic conditions, which increase the likelihood of infections within both the mother and the newborn. Tetanus typhoid immunization is one method of reducing deaths due to tetanus, but many other infections can occur at the time of birth. Infection ranks third among the causes of maternal mortalities in Egypt. A cohort study explored the use of a clean delivery kit as a means of reducing infant and maternal infections. Kits were distributed from primary health facilities, and birth attendants received training on how to use the kits. Results from the study of 334 women indicated that neonates of mothers who had the use of the kits were less likely to develop sepsis from cord infection and mothers had fewer postpartum infections (Darmstadt et al., 2009).
Pregnancy outcomes in Egypt are poorer as compared to those in other developing nations with similar per capita gross national products (GDPs). The national rate of low birth weight in Egypt is 12% of all live births, but for 30% of low-birth-weight infants in Egypt, the mortality rate is 2.5 times that of full-term infants. These increased risks of mortality for low-birth-weight children persist throughout the first year of life and beyond, with this risk factor also being associated with increased cognitive disabilities. A special antenatal nutrition project in Al-Minia, in Upper Egypt, demonstrated an ability to improve birth weight in newborns. Women in this project received food supplements and nutrition education as well as prenatal care and home visits. Results indicated that infant birth weights increased, which ultimately resulted in healthier babies who were less likely to contribute to the infant mortality rate (Ahrani et al., 2006).
Noncommunicable Diseases
Neuropsychiatric (19.8%), digestive diseases (11.5%), chronic respiratory diseases (6.9%), cardiovascular diseases (6.7%), and diabetes are major noncommunicable diseases whose incidence continues to increase in Egypt. Smoking, substance abuse, failure to use car seats and seat belts, lack of exercise, and consumption of fatty and salty foods are major contributors to the disease burden. Diabetes mellitus affects nearly 3.9 million people in Egypt, and its prevalence is expected to increase to 9 million by 2025. A study conducted in 2011 in Cairo indicated that type 1 diabetes mellitus care needs to be carefully monitored, as complication rates were nearly 50% among patients in the study. Regular exercise for patients in this study demonstrated a significant positive effect for children and adolescents (Ismail, 2011).
TABLE 3-3 Top Five Cancers in Egypt
Males
Females
Both Sexes
1. Bladder
1. Breast
1. Breast
2. Liver
2. Non-Hodgkins lymphoma
2. Bladder
3. Non-Hodgkins lymphoma
3. Ovary
3. Non-Hodgkins lymphoma
4. Lung
4. Colorectal
4. Liver
5. Leukemia
5. Leukemia
5. Leukemia
Source: WHO, 2011.
Table 3-3 lists the top five most frequently occurring cancers in Egypt. Breast cancer accounts for 38% of all new cancer cases among women living in this country. The age-standardized rate (ASR) for breast cancer incidence in Egypt is 37.3 per 100,000, and the mortality rate is 20.1 per 100,000. Incidence of breast cancer is lower in Egyptian women than in U.S. women, possibly due to a lower rate of cancer screening, and mortality rates for Egyptian women are higher than those for U.S. women (International Agency for Research on Cancer, 2010).
Mortality and Burden of Disease
Table 3-4 provides child mortality data for Egypt in 2009 and 2010. Table 3-5 lists adult mortality rates, defined as the probability of dying between 15 and 60 years of age per 1000 population; a breakout is provided for the maternal mortality rate. Table 3-6 identifies age-standardized mortality rates by cause. Table 3-7 gives causes of death for Egyptian children younger than age five. Table 3-8 provides mortality data related to HIV/AIDS, tuberculosis, and malaria.
TABLE 3-4 Child Mortality in Egypt, 2009 and 2010
Year
Rates
Under-five mortality rate (probability of dying by age 5 per 1000 live births)
2010
22
Number of under-five deaths (thousands)
2010
41
Infant mortality rate (probability of dying between birth and age 1 per 1000 live births)
2010
19
Number of infant deaths (thousands)
2010
35
Neonatal mortality rate (per 1000 live births)
2010
9
Number of neonatal deaths (thousands)
2010
18
Stillbirth rate (per 1000 total births)
2009
13
Source: WHO, 2011.
TABLE 3-5 Adult Mortality in Egypt, 2008 and 2009
Year
Number of Deaths Among Persons Aged 15–60 Years per 1000 Population
Male
2009
215
Female
2009
130
Both sexes
2009
174
Maternal mortality ratio (per 100,000 live births; interagency estimates)
2008
82 (range: 51–130)
Source: WHO, 2011.
Female Circumcision
Female circumcision has been a tradition in Egypt since the Pharaonic period. The prevalence of female circumcision is widespread in Egypt; 91% of all women age 15–49 have been circumcised. The female circumcision rate among women younger than age 25 is lower than the corresponding rate in the 25–49 age group, in which 94% to 96% of women have been circumcised. The rate also is lower among never-married than ever-married women (81% and 95%, respectively). Urban women are less likely to be circumcised than rural women (85% and 96%, respectively). The likelihood that a woman is circumcised also declines with the woman’s education level and is markedly lower among women in the highest wealth quintile than in other quintiles (78% versus 92% or higher). The majority of circumcised women (63%) report that (midwives) were responsible for performing the procedure. Trained medical personnel (primarily doctors) performed most of the remaining circumcisions (Egypt Demographic and Health Survey, 2008).
Spousal Violence in Egypt
Nearly three-fourths of women visiting family health centers in Alexandria, Egypt, have experienced spousal violence in their lifetimes. Approximately half of the women experienced physical violence (“Spousal Violence in Egypt,” 2010).
Mental Health
TABLE 3-6 Age-Standardized Mortality Rates by Cause, 2008 (per 100,000 population)
Mortality rate from communicable disease
76
Mortality rate from noncommunicable disease
749
Mortality rate from injuries
34
Source: WHO, 2011.
A national household survey of prevalence of disorders in five governorates, using the Mini International Neuropsychiatric Interview–Plus (MINI-Plus) instrument, indicated that almost 17% (range: 11% to 25.4% in different governorates) of adults in Egypt had mental disorders, with the common being mood disorders (6.4%), anxiety disorders (4.9%), and somatoform disorders (0.6%). Psychoses were seen in 0.3% of the population (WHO, 2005).
TABLE 3-7 Causes of Death Among Children Younger Than Age Five Years, 2008 (percentage of all deaths)
Prematurity
30
Pneumonia
11
Diarrhea
6
Birth asphyxia
5
Injuries
5
Neonatal sepsis
1
HIV/AIDS
0
Measles
0
Malaria
0
Other
23
Source: WHO, 2011.
Environmental Problems
Air pollution, especially in Cairo and Alexandria, is a major source of chronic respiratory diseases (WHO, 2006). According to the Country Cooperation Study, Egypt receives 98% of its fresh water from the Nile River; unfortunately, there is excessive water pollution in the Nile due to large discharges of pesticides, nutrients, and heavy metals from industry in Cairo, making obtaining clean water a major health challenge for the country’s population. Tap water assessments indicate that lead levels are at a high risk level as well. A recommendation by the WHO suggested that lead and other heavy metal residuals should be lowered for health safety of the population (Lasheen, El-Kholy, Sharaby, Elsherif, & El-Wakeel, 2008).
TABLE 3-8 HIV/AIDS, Malaria, and Tuberculosis in Egypt, 2008 and 2009
Year
Data (Range)
Deaths due to HIV/AIDS (per 100,000 population per year)
2009
0.6 (0.5–0.9)
Deaths due to malaria (per 100,000 population per year)
2008
0.2 (0.1–0.2)
Deaths due to tuberculosis among HIV-negative people (per 100,000 population per year)
2009
1.10 (0.74–1.50)
Prevalence of HIV among adults aged 15 to 49 (%)
2009
<0.1
Incidence of tuberculosis (per 100,000 population per year)
2009
19.0 (16.0–22.0)
Prevalence of tuberculosis (per 100,000 population)
2009
30.0 (13.0–49.0)
Source: WHO, 2011.
Egypt’s Response to the Millennium Development Goals
The tables presented in this subsection profile Egypt’s responses to WHO’s Millennium Development Goals (WHO Global Health Observatory Data Repository, 2011):
■ MDG 1: Poverty and hunger (Table 3-9)
TABLE 3-9 Egypt: Hunger Indicators, 2008
Male
Female
Both Sexes
Percentage of children younger than 5 years who are underweight
8.1
5.4
6.8
Percentage of children younger than 5 years who are stunted
33
28.4
30.7
Source: WHO, 2011.
■ MDG 4: Child mortality (Table 3-10)
TABLE 3-10 Egypt: Child Mortality Indicators, 2009 and 2010
Year
Data
Under-five mortality rate (probability of dying by age 5 per 1000 live births)
2010
22
Number of under-five deaths (thousands)
2010
41
Infant mortality rate (probability of dying between birth and age 1 per 1000 live births)
2010
19
Number of infant deaths (thousands)
2010
35
Measles (MCV) immunization coverage among 1-year-olds (%)
2009
95
Source: WHO, 2011.
■ MDG 5: Maternal health
• Maternal mortality (Table 3-11)
• Births attended by skilled health personnel, 2008: 79%
• Reproductive health (Table 3-12)
TABLE 3-11 Egypt: Maternal Mortality Indicators, 2008
Maternal mortality ratio (per 100,000 live births; interagency estimates)
82 (range: 51–130)
Births attended by skilled health personnel
79%
Source: WHO, 2011.
TABLE 3-12 Egypt: Reproductive Health Indicators, 2006 and 2008
Year
Data
Contraceptive prevalence
2008
60.3%
Contraceptive prevalence, among women aged 15–19
2008
23.4%
Adolescent fertility rate (per 1000 girls aged 15–19 years)
2006
50
Antenatal care coverage: at least one visit
2008
74%
Antenatal care coverage: at least one visit, among women aged 15–19
2008
76.5%
Antenatal care coverage: at least four visits
2008
66%
Unmet need for family planning
2008
9.2%
Unmet need for family planning: women aged 15–19
2008
7.9%
Births attended by skilled health personnel, among women aged 15–19
2008
78.8%
Source: WHO, 2011.
■ MDG 6: HIV/AIDS, malaria, and other diseases (Table 3-13)
TABLE 3-13 Egypt: HIV/AIDS, Malaria, and Tuberculosis Indicators, 2008 and 2009
Year
Data
Prevalence of HIV among adults aged 15–49 (%)
2009
<0.1
Deaths due to malaria (per 100,000 population per year)
2008
0.2 (0.1–0.2)
Incidence of tuberculosis (per 100,000 population per year)
2009
19.0 (16.0–22.0)
Prevalence of tuberculosis (per 100,000 population)
2009
30.0 (13.0–49.0)
Deaths due to tuberculosis among HIV-negative people (per 100,000 population per year)
2009
1.10 (0.74–1.50)
Case detection rate for all forms of tuberculosis
2009
63 (54–75)
Smear-positive tuberculosis treatment: success rate (%)
2008
89
Source: WHO, 2011.
■ MDG 7: Environment sustainability (Table 3-14)
TABLE 3-14 Egypt: Water and Sanitation Indicators, 2008
Urban
Rural
Total
Population using improved drinking-water sources
100%
98%
99%
Population using improved sanitation facilities
97%
92%
94%
Source: WHO, 2011.
■ Not a MDG. The following is a table relating nutrition in Egypt (Table 3-15).
TABLE 3-15 Egypt: Nutrition Indicators, 2008
Male
Female
Both Sexes
Children younger than 5 years: overweight
19.8%
21.2%
20.5%
Children younger than 5 years: stunted
33%
28.4%
30.7%
Children younger than 5 years: underweight
8.1%
5.4%
6.8%
Children younger than 5 years: wasted for age
8.8%
7.1%
7.9%
Source: WHO, 2011.
Traditional Health
In the Arab Republic of Egypt, a national policy on traditional medicine/complementary alternative medicine (TM/CAM) is part of the national drug policy that was issued in 2001. Herbal medicine regulation in Egypt began in 1955, and is achieved through the same laws as are applied to conventional pharmaceuticals. Herbal medicines are regulated in the forms of prescription medicines, over-the-counter medicines, self-medication, and dietary supplements. Control mechanisms exist for both manufacturing and safety assessment requirements. There are 600 registered herbal medicines, though no herbal medicines are included on the national essential drugs list. In Egypt, herbal medicines are sold in pharmacies by licensed practitioners, as over-the-counter products, and as prescription medicines (WHO, 2011).
CHINA
Description
China is the world’s fourth largest country in area (after the countries of Russia, Canada, and the United States), and is located in east Asia, bordering numerous countries, including the Russian Federal Republic, India, Pakistan, Vietnam, and Mongolia. China, which is slightly smaller than the United States, has climates varying from tropical in the south to subarctic in the north. At present it has a great amount of air pollution—mostly greenhouse gases and sulfur dioxide particles from use of coal and other carbon-based fuels. It also has water pollution, hazardous waste, deforestation, and soil erosion problems (Central Intelligence Agency [CIA], 2011a).
Population
China currently has 1.3 billion people. A graph of China’s aging population and the forecast for the increased percentage of the total population represented by people 65 and older can be seen in Figure 3-1. Table 3-16 provides a breakdown of China’s health and vital statistics.
Ethnic Groups in China
The Han ethnic group makes up 91.9% of the population, with the remainder being Zhaung, Uygur, Hui, Yi, Tibetan, Miao, Manchu, Mongol, Buyi, Korean, and other nationalities. The official religion of China is atheist, but 1% to 2% is Daoist, Buddhist, or Muslim, and 3% to 4% is Christian. The standard language is Mandarin; other dialects spoken in the country include Cantonese, Shanghaiese, Fuzhou, Hokkien-Taiwanese, Xiang, Gan, and Hakka. China has a 91.6% literacy rate (CIA, 2011a).
FIGURE 3-1 China’s Aging Population
Source: Quoted from the website of the National Bureau of Statistics of the People’s Republic of China, www.stats.gov.cn
TABLE 3-16 China’s Population, 2010
Total population
1.330 billion people
Birth to 14 years
17.9%
15–64 years
73.4%
65+ years
8.6%
Population growth rate
0.494%
Birth rate
12.17 per 1000 people
Death rate
6.89 per 1000 people
Gender ratio
1.08 males per 1 female
Infant mortality rate
16.51 deaths per 1000 live births
Males: 21.21 deaths per 1000 live births
Females: 27.5 deaths per 1000 live births
Life expectancy at birth (ranks 92nd in world)
Males: 72.54 years
Females: 76.77 years
Fertility rate
1.54 children per woman
HIV rate
0.1% (700,000 persons already have the disease)
Education (average)
11 years
Literacy (can read and write)
91.6%
Source: CIA, 2011a.
Government
The government of China (also called the People’s Republic of China [PRC]) is communist, and the capital is in Beijing. China has 23 provinces and 5 autonomous regions (CIA, 2011a).
Economy
Since 1978, the Chinese economy has moved from a centrally run and planned Soviet-style of government to a market economy. Business and agriculture are now more locally run, rather than being controlled by the central communist government. The overall economic system continues to function within strict communist political control, however. The change in management style of business has increased the GDP four times and boosted per capita income to $8288 in 2011 (CIA, 2011a).
China has now moved beyond Japan to become the world’s second-largest economy, and it may overtake the United States in terms of national income within the next 10 years, though it remains far behind in per capita income. The country now has hundreds of millions of people who have moved out of poverty and has a large group of students and tourists who visit the West. In spite of China now having many billionaires, as well as numerous millionaires, the average income for most of its residents is still among the world’s lowest (“China Surges Past Japan,” 2010).
Healthcare System
History
China has one of the longest historical records of medicine of any existing civilization in the world. Both traditional medicine and new technology are components of the Chinese healthcare system.
In 1949, Chairman Mao Zedong established a rural preventive healthcare program, emphasizing disease prevention. At that time, the ministry of public health was made responsible for all health care. Large numbers of more sophisticated urban physicians were sent to the countryside to practice. In addition, less trained “barefoot doctors” were sent to small rural communities to help supply the needs for local rural health care. They worked out of village medical centers, providing preventive and primary medical care. In addition, township health centers that had 10–30 bed hospitals were established as part of the so-called rural collective health system. Only seriously ill patients went to county hospitals, which served a much larger population base. In large urban areas, health care was provided by paramedical personnel, who were assigned to factories and neighborhood health stations. Patients with serious illnesses went to the district or municipal hospitals.
In the 1950s, China was isolated by the Western powers, and the Soviet Union was its only ally. During this era, medical schools and hospitals in China were built with the help of Russians. There was an emphasis on public health and prevention of illness. The government mobilized the people to begin massive patriot health campaigns aimed at environmental sanitation and preventing disease. An example was the assault on the “four pests” (rats, sparrows, flies, and mosquitoes), as well as the efforts directed toward eradicating snails that carried schistosomia disease. Other health campaigns were devoted to water quality and waste management (CIA, 2011a). Unfortunately, much of the country’s agricultural sector was ignored or handled poorly by overplanting and not harvesting all the crops, leaving them to rot. Thus many of the agricultural programs failed. As many as 20 to 30 million people starved to death, and infant mortality rose to 300 per 1000 (Hesketh & Zhu, 2002).
In the 1960s, campaigns to prevent sexually transmitted diseases, such as syphilis, were successful. By the 1970s, China was able to set up affordable primary health care in the rural areas. During the 1980s, its health policy was restructured based on market-driven reforms. The barefoot doctors were then less needed, as a more sophisticated system of health care was established. With a 1% growth rate and a population of 1.3 billion people, China became very concerned about population growth and began restricting family size by implementing the “one child per family” policy. Diseases such as tuberculosis, hepatitis, hookworm, and schistosomiasis still remained problems. Later, other, more chronic diseases such as HIV/AIDS, cancer, cardiovascular disease, and heart diseases became frequent causes of mortality, similar to the situation in other developed societies (CIA, 2011a).
According to Freedom House (an organization that judges how much freedom citizens of various countries have), China is near the bottom of the list of countries for limiting freedom. It is possible that these restrictions actually helped the healthcare system in China, however. From the 1950s to the 1970s, health care in China improved greatly under a very strict authoritarian rule. Brothels and opium dens were officially closed, the four pests (flies, mosquitoes, rats, and sparrows) were greatly reduced, and the training of a million barefoot (lay) doctors by urban doctors was accomplished. Health care through prevention was promoted. The communist government claimed that incidence of sexually transmitted diseases, schistosomiasis, and leprosy decreased, access to health care for all was promoted, and infant mortality decreased. It is almost impossible to verify all of these claims, however, because China was a closed system that allowed few outsiders to document facts. The irony today is that as China becomes freer and turns toward a more market-driven economy, some advances in health care have actually been reversed. For example, universal access to health care for all is gone, and poor rural Chinese have great difficulty today getting prevention and treatment under the current partial out-of-pocket payment system (Hesketh & Zhu, 2002).
China, through its market reforms, has experienced tremendous economic growth. One of the results of the economic upturn has been the establishment of a fee-for-service private medical practice with few governmental restrictions. Private medical practice was not allowed during the Cultural Revolution, but it reemerged in the 1980s after the dissolving of the Cooperative Medical System (CMS) during the Maoist times, when many people lived in communes. At present, rural families must pay out-of-pocket fees for medical services; these often prohibitive costs render health care inaccessible for many (Lim, Yang, Zhang, Feng, & Zhou, 2004).
The Chinese barefoot doctors today in the small remote villages of the far west are often supported by a very small government salary each month and typically work out of their homes rather than a clinic, which enables them to maintain their farms when there are no patients. The doctors charge a small fee to the patients for their services, and the remainder of their salaries comes from drug sales. Often doctors overprescribe medicines simply to increase their incomes. Village doctors have inadequate training and often do not take patient histories or keep medical records as part of China’s economic reforms. The Chinese government has increasingly cut the funds made available for health care, so by 2000, 60% of all healthcare costs were paid for by the individual. The typical city doctor earns $600 to $1200 per month and sees 60 to 80 patients per day. The government has recently budgeted $350 million dollars to establish disease control and prevention centers in poor areas. Many poor areas had difficulty treating severe acute respiratory syndrome (SARS) cases when this disease emerged in China because of the inadequate resources (“Life as a Village Doctor,” 1997).
Access to Health Care and Costs
Since the 1980s, the Chinese government has had a laissez-faire policy for health care in rural areas. As part of that policy, it reverted to a self-pay system for clinic visits and hospitalization, which are now both very expensive relative to income. One average hospitalization costs 50% more than the average annual income. Access to health care in many areas is now priced on a sliding scale based on the ability to pay, yet many people are still unable to afford health care. In urban areas, medical care includes the use of high technology. The government health insurance program has given more equal access to health care, but cost inflation is now a major governmental concern. Copayments were first started to make the users more aware of health costs when accessing medical care. Medications and high-tech tests are now charged to patients and not covered by the government insurance.
The majority of China’s population lives in rural areas. Those who live in urban areas are in many ways advantaged. The distinction between rural and urban subpopulations is reinforced by a system of population registration that limits migration from rural to urban areas (Zimmer & Kwong, 2004).
In recent years, China has made great efforts to improve its public health system. Funds have been expended to modify and enlarge the disease prevention and control centers and to establish emergency centers and hospitals throughout the country. The major infrastructure has been improved. The ministry of health set up 10 national medical teams for disaster relief and disease prevention in some of the major cities. The SARS epidemic was controlled rapidly with through this new infrastructure (Zheng, 2005).
China has the most hospitals (60,784) and the most doctors (1.97 million) of any country in the world. In 1949 when the Communists came to power there were only 2,600 hospitals in China. There are now 17 doctors per 10,000 people which compares to 25 doctors per 10,000 people in the United States. About 4.5 percent of the gross domestic product (GDP) is allocated to health care, half of which comes from the private sector. By comparison the average healthcare expenditure of countries in the European Union is 9 percent of GDP, while in the United States, it is closer to 16 percent (Hays, 2011).
Government insurance programs have been expanded in recent years to decrease the out-of-pocket payments and lack of equity in healthcare availability and quality. With China’s strong economic growth and huge financial reserves, it has the potential of decreasing the health disparities and improving access to and quality of healthcare nationwide (Hu, Tang, Liu, & Zhao, 2008). The Chinese government is hoping to establish a universal healthcare plan and plans to overhaul most of its inadequate hospitals by 2011; the government also approved a plan to spend $124.3 billion by 2012 on healthcare improvements. The plan is to provide annual health subsidies to citizens as well as to implement a system to provide drugs and vaccines. In 2007, WHO ranked the healthcare system of China as number 144 out of 190 nations, well below the systems found in far poorer countries such as Haiti (Wang, 2009).
The makeup of the current healthcare workforce in China differs from that in many other nations. China has more doctors than nurses. In 2005, there were 1.9 million licensed doctors and 1.4 million licensed nurses. The density of healthcare providers is much greater in urban as compared to rural areas—specifically, a 3:1 ratio. Most doctors and nurses have only a junior college or high school level of education. Approximately one-third of physicians and nurses have been educated at the college level or higher. The majority of the higher-educated healthcare workers can be found in the urban areas, which creates a great disparity in the quantity and quality of healthcare providers in urban versus rural areas (Anand, Fan, & Zhang, 2008).
Health Priorities
China has experienced rapid growth in social and economic development that has created a demand for high-quality health care within the country. The life expectancy of the average person has increased, and this trend is expected to create an aging population with chronic health problems. The leading cause of death in those 1–44 years is injury. Approximately 750,000 deaths and 3.5 million hospitalizations occur each year. More people are now using motorcycles and cars, and fewer people are walking or using bicycles. As a result of changes in diet and activity, cardiovascular disease is increasing rapidly. Nearly 2.6 million deaths occur annually from this problem, but by 2020 it is projected that 13 million people will die each year from cardiovascular disease (George Institute for International Health, 2003).
Environmental Health Issues and Respiratory Problems
China’s movement toward a market economy has increased incomes and improved health indicators for its population but created some difficult environmental problems. Biomass fuel and coal are burned in most of China for cooking and heating in most rural areas and a significant number of urban areas, which contributes to a major problem with indoor air pollution. In addition, the country has intense pollution from coal combustion for industry, which is damaging the air, water, and ultimately the agriculture, which in turn affects the residents’ health. Of the 10 most polluted cities of the world, China is home to 7 of them. China is also the world’s second highest emitter (after the United States) of carbon dioxide pollution, mainly from industry. With the help of the United Nations and the United States, China hopes to develop a multimillion-dollar energy strategy to combat pollution (Zhang & Cai, 2003).
Respiratory diseases are now a widespread and serious issue. Driven by China’s tremendous industrial growth, the pollution that causes these diseases is taking a heavy toll on both the environment and public health. High rates of smog from industrial and traffic pollution are associated with very high rates of respiratory infections and chronic illnesses. China relies heavily on coal that contains high levels of sulfur; this fuel is used to satisfy 70% of the country’s domestic energy needs (Zhang & Cai, 2003).
Water pollution is another major problem. Half of all of China’s water sources are considered too polluted for human consumption. Air and water pollution in China is estimated to cause 2.4 million premature deaths per year from cardiopulmonary and gastrointestinal diseases. Increases in the use of fossil fuels in industrial and residential use increases the country’s production of greenhouse gases, which in turn poses significant health risks to the population. Significant health disparities exist between poor and wealthy populations, related to the exposure to polluted air and water in poorer households (Zhang, Mauzerall, Zhu, Liang, Ezzati, & Remais, 2010).
Lead poisoning is a concern among many residents. In 2009, approximately 2000 children living near zinc and manganese smelting plants in two provinces were found with unsafe levels of lead in their blood—a revelation that provoked riots (Watts, 2009).
A major food safety incident in China was made public in 2008. An estimated 300,000 infants and young children were made ill and 6 died after melamine was deliberately added to diluted raw milk as well as other food and feed products. This additive led to formation of kidney stones and renal failure. Twenty-two manufacturers of infant formula sold this contaminated product, in what is considered one of the largest ever food contamination incidents—which also had implication for international food safety (Gossner et al., 2009).
Tobacco smoking, especially among adult males, is another growing environmental problem in China that has caused many respiratory diseases and deaths. China makes and sells more cigarettes than any other country in the world and has more than 350 million smokers, which represents about one-third of the population. Rates are highest among adult men, who have a 67% smoking rate; in contrast, only 4% of all females smoke. Cigarette smoking is now the leading cause of preventable deaths in China (and the rest of the world). It seems inevitable that China will see a tremendous increase in mortality from smoking-related diseases such as chronic obstructive pulmonary disease (COPD), lung cancer, and pulmonary tuberculosis. The China National Tobacco Corporation is the largest tobacco manufacturer in the world. As part of an effort to stem the tide of smoking, the Minister of Health publishes an annual tobacco control report and campaigns have been launched to increase tobacco taxes and put health warnings on the tobacco products beginning in January 2009 (Gonghuan, 2010).
Mental Health
Mental health is a major issue in China today because of the rapid social and economic changes. Changes that some members of the population face today include financial losses from bad business deals and gambling; higher rates of extramarital affairs, family violence, and divorce; rising rates of substance use and abuse; weakening of traditional family values and relationships; large numbers of rural migrants seeking employment in larger urban environments; a widening gap between the rich and poor; work-related stress; and a faster pace of life. Eighty percent of the country’s healthcare budget goes to the urban residents, even though they represent only 30% of the total population. Funds for mental health are very limited for the rural population, most of whom cannot afford the out-of-pocket costs for mental health care. Shanghai, the largest population in China, boasts having the most comprehensive mental healthcare system in the country (Chang & Kleinman, 2002).
According to 2003 WHO data, 13% of the Chinese population has psychological problems, and 16 million people in China suffer from serious mental illness. Every year in China, some 280,000 people commit suicide, accounting for 25% of the entire world’s suicide statistics. Another 20 to 50 million people attempt suicide each year. Suicide is the fifth leading cause of death for Chinese people 15–35 years of age. The suicide rate in China is three times higher in rural areas as compared to urban areas. This rate is 25% higher among women than men, a trend that is the opposite of that found in many other nations of the world. The higher rates of female suicides in rural areas are primarily due to poverty, the low status of rural women, forced marriages, family violence and conflict, chronic stress, and no hope for the future. Men in rural areas are often absent from the homes for long periods of time, leaving the women to work in the fields, take care of children, cook, and care for the house (Pochagina, n.d.).
Nutrition
Throughout China, there has been a change in diet and physical activity and overall body composition patterns. During the past 10 years, the number of people living in China in absolute poverty has significantly declined. The proportion of those considered extremely poor decreased from 20% to 6% of the total population during the same period. As a result of this change in economic status, the prevalence of obesity and diet-related noncommunicable diseases has increased more rapidly in China than in other developed societies. Diets have shifted from high-carbohydrate to high-fat and high-density energy foods, leading to overweight and obesity—and their associated diseases, such as diabetes, stroke, cancer, and cardiovascular diseases (Du, Mroz, Zhai, & Popkin, 2004).
Cardiovascular Disease
Cardiovascular disease is the leading cause of mortality in the world, including in China and other developing countries. China and other developing nations have been experiencing an epidemic in cardiovascular disease during the last few decades mainly because of lifestyle and diet changes. Currently, there is a growing prevalence of metabolic syndrome and overweight individuals among adults in China. Metabolic syndrome is characterized by a cluster of problems that consists of abdominal obesity, increased blood pressure and glucose concentration, and elevated cholesterol levels. Obesity is a risk factor not only for cardiovascular disease but also type 2 diabetes, hypertension, and cancer. Excess weight is also a cause for osteoarthritis and gallbladder disease (Dang, Yan, Yamamoto, Wang, & Zeng, 2004; Gu et al., 2005).
Infectious Diseases
Major infectious diseases in China include the following (CIA, 2011a):
■ Food- and water-borne diseases (bacterial diarrhea, hepatitis A, and typhoid fever)
■ Vector-borne diseases (Japanese encephalitis and dengue fever)
■ Soil-contact diseases (hantaviral hemorrhagic fever and renal syndrome)
■ Animal contact diseases (rabies)
HIV/AIDS
HIV/AIDS entered China in 1985, and more than 20 years later the epidemic continues to spread at an alarming rate. The CIA (2011a) has estimated that 0.1% of the total Chinese population is infected with HIV; this rate, compared to that found in other parts of the world, ranks 115th worldwide. It translates into 700,000 adults living with HIV/AIDS, which ranks as the 17th largest population with this disease in the world. The estimated number of deaths from this cause—39,000 per year—places China at 15th worldwide in AIDS deaths (Kanabus, 2005).
The general population of China knows little about the sexual practices that increase the risk of contracting HIV infection. HIV/AIDS prevention in the general population has been rare. Those now living in China with HIV/AIDS face severe discrimination and have limited access to healthcare services, especially in the rural areas (Chen, Han, & Holzemer, 2004). The government has promised to provide free HIV tests to anyone who wants one and fully cover treatment costs for poorer patients (Kanabus, 2005).
Tuberculosis
China reported the worldwide second-highest number of new tuberculosis (TB) cases (1.31 million) and the second-highest number of TB deaths (201,000 TB cases) in 2007, behind only India. China has 4.5 million TB cases currently, and each year 1.4 million people fall ill with the disease. TB killed 160,000 people in China in 2008, according to WHO. TB also represents a big drain on China’s health budget because of the high incidence of people with a drug-resistant strain of the disease, which is much more difficult and expensive to treat; these patients need to take drugs for up to two years. This worst type of TB, for which there is no cure, kills one out of every two patients. Regular TB costs 1000 Yuan ($158.60) to treat in China, whereas drug-resistant TB costs range from 100,000 to 300,000 Yuan ($15,900 to $47,600) per person. China spent $225 million on tackling TB in 2008, up from $98 million in 2002, according to WHO. (These figures do not take into account the amounts that patients pay out of their pockets, which typically amounts to between 47% and 62% of their hospital bills.) The World Bank funded the first TB survey in China, which was followed by a new program that aimed to treat the cases and prevent new ones (“China Fights Growing Problem of Tuberculosis,” 2010).
Population Control
China has only 7% of the world’s arable land, yet 22% of the world’s population. To feed, house, and promote good health care for this country’s citizens despite the relatively scarce resources, the “one child per family” policy was established by Chinese leader Deng Xiaoping in 1979 to limit China’s population growth. The advantages of such a policy are that each child will have a healthier life, family costs will be lower, and the child will get a better education. Women will be able to focus on their careers as well as on care for their families. The government claims that this policy has prevented mass starvation.
Fines, pressures to abort a pregnancy, and even forced sterilization occur with subsequent pregnancies after the first. The policy includes ethnic Han Chinese living in urban areas. Citizens living in rural areas and minorities living in China are not subject to the law. The “one child” policy has estimated to have reduced the population of the country by as much as 300 million people in the past 20 years. A new law in addition to the “one child” regulation states that if both parents have no siblings, they may have two children, thus preventing too dramatic a population decrease.
One problem with this population control policy is that Chinese parents usually rely on their children—especially their sons—for support in their old age. The result is that most couples want a male child if they can have only one child (Population—China, 2004). In turn, sex selection during pregnancy (e.g., through ultrasound and subsequent abortion of female fetuses) has resulted in a ratio of 114 males to 100 females among children from birth to 4 years old. Over time, the population control policies have caused serious problems for female infants such as abortion, neglect, abandonment, and even infanticide (Rosenberg, 2011).
Internal Migration and Its Healthcare Implications
China has a highly mobile population of 140 million rural-to-urban migrants representing 10% of the total population. Migrants move between cities and provinces in search of improved living conditions. Most are young, single males, who have a socioeconomic status above rural groups but below urban populations. Migrants are excluded from urban healthcare services, including access to public health facilities, and they do not qualify for public medical insurance and other assistance programs. They must pay out-of-pocket for medical services in the cities. Within this population are individuals who pose special concerns given their spread of communicable diseases such as sexually transmitted diseases (STDs), respiratory infections such as TB, diarrheal infections, and parasitic infections. A second concern is maternal and infant health for members of migrant groups; such care is also not covered by public insurance to migrants. Lastly, occupational diseases and injuries have become a significant problem among this group, given their lack of public insurance coverage (Hu, Cook, & Salazar, 2008).
Traditional Medicine
The practice of traditional Chinese medicine was strongly promoted by Chinese leaders, and it has remained a major part of health care. Western medicine gained acceptance in the 1970s and 1980s. The goal of China’s medical personnel is to synthesize the use of both Western and traditional Chinese medicine, yet this practice has not always worked seamlessly. Physicians trained in traditional medicine and those trained in Western medicine are very separate groups with different basic ideas. Traditional Chinese medicine uses herbal treatments, acupuncture, acupressure, moxibustion, and cupping of skin with heated bamboo. These approaches are very effective in treating minor ailments and chronic diseases, and they produce far fewer side effects. Some more serious and acute problems are also treated with traditional medicine. For more information regarding this topic see the chapter entitled, “Global Use of Complementary and Alternative Medicine.”
INDIA
History
The Indus Valley civilization, one of the world’s oldest, was a vibrant presence during the second and third millennia b.c.e. Aryan tribes from the northwest came to the Indian subcontinent in 1500 b.c.e., merging with the earlier Dravidian people and creating the classical Indian culture. Many years later in the nineteenth century, India came under British rule. Nonviolent resistance to British rule, led by Ghandi and Nehru, brought India to independence in 1947. Violence in the new state eventually led to a partition of the nation, creating two countries, India and Pakistan. Later, a war in 1971 resulted in East Pakistan becoming the country of Bangladesh (CIA, 2011b).
Geography
The country of India is located in southern Asia, bordering the Arabian Sea and the Bay of Bengal, between Burma and Pakistan. It has a large land area, ranking seventh in the world. The climate includes monsoons in the south and a more temperate climate in the north. The country’s natural resources include coal (India has the fourth largest reserves in the world), iron ore, manganese, mica, titanium ore, natural gas, diamonds, and petroleum, among others. Within this country there is an abundance of deforestation, soil erosion, overgrazing, air pollution from industry and vehicle emission, and water pollution from raw sewage and agricultural pesticides, making water nonpotable throughout the country (CIA, 2011b).
Population
India is home to 1.173 billion people, ranking the country second in the world in terms of population size. The population is growing at a rate of 2% annually, which will create the world’s largest population—surpassing China—by 2030. By 2050, India’s population is expected to reach 1.6 billion people. The population increase is due to increases in life expectancy, decreases in infant mortality, and emphasis on eradication of diseases such as hepatitis, tetanus, and polio among infants. The median age is 25.9 years, with approximately 30% of the population being younger than 14 years, 64.6% being between the ages of 14 and 64 years, and 5.3% being 65 years or older. The birth rate is 21.34 births per 1000 population; the death rate is 7.53 deaths per 1000 population. The infant mortality rate is 49.13 deaths per 1000 live births. Life expectancy is 66.46 years, ranking 159th in the world.
The majority of India’s people live in a rural agrarian economy and have incomes of less than $1 per day (CIA, 2011b). Only 29% of the total population lives in urban areas.
Infectious Diseases
The HIV/AIDs rate in India is 0.3% (2007 estimate) of the total population, with 2.4 million (2007 estimate) people living with HIV/AIDS, and 310,000 deaths occurring from this cause (2001 estimate). Food-and water-borne diseases cause a high rate of bacterial diarrhea, hepatitis A and E, and typhoid fever. Vector-borne diseases include chikugunya, dengue fever, Japanese encephalitis, and malaria. Rabies is caused from animal contact, and leptospirosis is caused from water contact. India’s malaria and TB rates are ranked third in the world (CIA, 2011b).
Chronic Diseases
India is now faced with a double burden of long-term chronic illnesses and serious acute illnesses. Cardiovascular diseases, cancer, degenerative diseases, and diabetes have become major health issues in addition to the acute communicable diseases mentioned previously.
Culture
Indians practice a number of different religions: Hindu (80.5%), Muslim (13.4%), Christian (2.3%), Sikh (1.9%), other (1.8%), and unspecified (0.1%). English is the official language, yet Indians use many other languages as well. Hindi is the most widely used of these languages (used by 41% of the population), but 14 other languages are also spoken. Approximately 61% of the population is literate, being able to read and write, and the average education level is 10 years. Inequality of opportunity has caused the lower-caste Hindus, Muslims, tribal people, and other minority populations to be disproportionately represented within the poor, the uneducated, and those with most health problems (CIA, 2011b).
Government and Economy
India is a federal republic with New Delhi as its capital city. The country contains 28 states and 7 union territories. The economy is developing into an open-market economy, which encompasses traditional village farming, modern agriculture, handicrafts, and a wide range of services, including information technology and software workers. India’s annual per capita income is $3100 (2009 estimate). The country has a significant labor force of 467 million people (second largest in the world) and has 81 million people using the Internet (the fourth largest group of users in the world). The unemployment rate is 10.7%. The Indian pharmaceutical market has grown rapidly in the past few years and the federal government uses price controls to ensure that vital drugs are available to the general population (CIA, 2011b).
Health Care
Health care is the responsibility of each state or territory of India. Each state is expected to pay for 80% of healthcare facilities, and the federal government pays 15%, mainly through national healthcare programs. Health care in India can be traced back 3500 years to the inception of Ayurvedic traditional medicine, which is still used today. India has historically suffered from great famines, which have been eradicated, yet continues to experience significant problems with malnutrition, starvation, and disease, especially in the rural areas.
Undernutrition rates in children in India are higher than sub-Saharan Africa. Approximately 46% of children from birth to 3 years are undernourished (Rao, 2009). A preference for male babies has led to an imbalanced ratio of 93.5 girls per 100 boys, in contrast to the natural gender ratio at birth of 105 males to 100 females. Maternal and infant death rates remain high. The vast majority of the Indian population suffers from waterborne and airborne infections. Most of the country lacks a basic infrastructure, as its development has not kept up with the growing economy. Almost 1 million people die each year due to inadequate health care, and 700 million people lack access to specialist care, which mainly exists in large urban areas. Forty percent of the healthcare facilities in India are understaffed (Rao, 2009).
The number of hospital beds is low—only 0.7 per 1000 population, compared to the world average of 3.96 hospital beds per 1000 population. In addition, India lacks an adequate number of trained healthcare personnel for its growing healthcare industry. Rural healthcare services are mainly provided by smaller primary healthcare centers, which rely on trained paramedics for most of the care. Serious cases are sent to urban areas, where specialists and acute care facilities are available. Skilled birth attendants are needed, yet are still not provided in adequate numbers to decrease the high rates of maternal and infant mortality (Rao, 2009).
Indigenous traditional medicine is practiced throughout the country. The main forms are Ayurvedic medicine, which addresses mental and spiritual well-being as well as physical well-being. In addition, Unani herbal medicine is practiced. Today only 25% of the Indian population has access to Western medicine (Rao, 2009).
The government has made a major commitment to telemedicine to reach the majority of the poor, rural, underserved population. Health insurance is inaccessible to the majority of Indians, and 75% of healthcare expenses are paid on an out-of-pocket basis, which is very challenging for the many people who live in poverty. Emergency and specialty care is well beyond the reach of most of the poor lower-class residents. Among those in the urban middle and upper classes, approximately 50% have private health insurance.
The National Rural Health Mission was begun in 2005 to provide major improvements in health care for the rural population. Primary healthcare clinics, which have social activist leanings, help support public health priorities such as childhood immunizations and compliance with TB treatments. The National Rural Health Mission program was established to address issues of poverty and provide 100 days of work at minimal wage to one family member per household. In addition, an increase in primary school enrollment, particularly among girls, was established as a goal.
SOUTH AFRICA
Geography
South Africa is located at the southern tip of the continent of Africa. It is bordered by Botswana, Lesotho, Mozambique, Namibia, Swaziland, and Zimbabwe, as well as the Atlantic and Indian Oceans. Its climate is mostly arid, with a subtropical region found along the country’s east coast. Natural resources include gold, chromium, antimony, coal, iron ore, manganese, nickel, phosphates, tin, uranium, gem diamonds, platinum, copper, vanadium, salt, and natural gas (CIA, 2012).
Population
South Africa’s population as of 2010 was approximately 47 million. The country is currently experiencing the world’s highest rate of people with HIV/AIDS, as well as the world’s highest mortality rate from this disease (see Table 3-17).
Ethnic groups in South Africa include the following (CIA, 2012):
■ Black African (79.6%)
■ White (9.1%)
■ Colored (8.9%)
■ Indian/Asian (2.5%)
Religions practiced include the following:
■ Zion Christian (11.1%)
■ Pentecostal/Charismatic (8.2%)
■ Catholic (7.1%)
■ Methodist (6.8%)
■ Dutch Reformed (6.7%)
■ Anglican (3.8%)
■ Other Christian (36%)
■ Islam (1.5%)
■ Other (2.3%)
■ Unspecified (1.4%)
■ None (15.1%)
Languages spoken in South Africa include the following:
■ IsiZulu (23.8%)
■ IsiXhosa (17.6%)
■ Afrikaans (13.3%)
■ Sepedi (9.4%)
■ English (8.2%)
■ Setswana (8.2%)
■ Sesotho (7.9%)
■ Xitsonga (4.4%)
■ Other (7.2%)
The literacy rate of the total population is 86.4%.
South Africa has the largest population of people of European descent in Africa, the largest Indian population in Africa, and the largest colored (mixed European and African) group in Africa. It is one of the most ethnically diverse countries in Africa. The country has had a long history of racial problems between the black majority and the white minority. The country’s Apartheid policy, which was introduced in 1948, ended in 1990. Crime remains a major problem in South Africa, which ranks first in the world in terms of number of murders by firearms, manslaughter, rape, and assault cases. It also ranks fourth in the world in terms of robbery incidence, according to a survey done by the United Nations during 1998–2000. Problems also persist with illegal drug transportation and sales (CIA, 2012).
TABLE 3-17 South Africa: Rates of HIV/AIDS
Population
47 million (2010 data)
Birth–14 years
30.3%
15–64 years
64.5%
65+ years
5.2%
Population growth rate
–0.31%
Death rate
21.32 per 1000 people
Infant mortality
61.81 per 1000 live births
Life expectancy
43.27 years
HIV/AIDS adult prevalence rate
21.5 % (2003 estimate)
Approximately 5 million people (20% of 15- to 49-year-old population and 35% of all women of childbearing age)
Source: Adapted from U.S. Department of State, Bureau of African Affairs, 2005.
The South African population is relatively young, with approximately one-third younger than age 15. Fertility is declining, and there is an increase in persons older than 60 years. The country’s healthcare services include not only services for obstetrics, pediatrics, and adolescents, but also those for the aging population. A large proportion of the population (18% in some areas) is illiterate. Half of all households use electricity for cooking (Bradshaw & Nannan, 2004).
Since 1994, life expectancy in South Africa has declined by 20 years, mainly because of the increase in HIV/AIDS incidence. The average life expectancy at birth is now 50 years for men and 54 years for women. The global burden of disease is quite high, and morbidity and mortality rates are very high due to HIV/AIDS, violence and injury, chronic diseases, mental health disorders, and maternal, neonatal, and child mortality (Chopra et al., 2009).
Government
The government is a republic, formally named the Republic of South Africa (RSA), with a legal system based on Roman-Dutch law and English common law. The system of government is also called a parliamentary democracy. South Africa has three capital cities: Cape Town, the largest, is the legislative capital; Pretoria is the administrative capital; and Bloemfontein is the judicial capital. The country comprises nine provinces (CIA, 2005; U.S. Department of State, Bureau of African Affairs, 2005).
Economy
South Africa has a two-tiered economy. One segment is similar to other economically strong developed countries, and the other is more like developing countries with only the basic infrastructure. South Africa has well-developed financial, legal, communication, energy, and transportation systems. It has the world’s tenth largest stock exchange and a modern infrastructure. It has the best telecommunications system in Africa. At the same time, South Africa has a very high unemployment rate (25%) and most of the country’s citizens live on less than $1.25 per day.
The country’s wealth is unevenly distributed, with the minority whites having a much larger portion of the wealth and the majority blacks having a very challenging existence with difficulty finding well-paying jobs. The country has an overall per capita GDP of $11,100 (2004 estimate). Its industries include mining (South Africa is the world’s largest producer of platinum, gold, and chromium), auto assembly, metalworking, machinery, textile, iron and steel, chemicals, fertilizers, ship repair, and foods (CIA, 2005; U.S. Department of State, Department of African Affairs, 2005). The main agricultural products are corn, wheat, sugarcane, fruits, vegetables, beef, poultry, mutton, wool, and dairy products (CIA, 2005; U.S. Department of State, Department of African Affairs, 2005).
Healthcare System
South Africa’s healthcare system consists of a large public sector and a smaller, yet fast-growing private sector. Basic primary health care is offered free to all residents of the country, but is highly specialized; high-tech care is limited to only those who can afford private care. The dilemma is that the government contributes approximately 40% of healthcare costs for the public health, yet 80% of the population uses the services. The number of public hospitals continues to grow, and companies in the mining industry operate their own 60 hospitals and clinics in different locations within the country (U.S. Department of State, Department of African Affairs, 2005; Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009).
Since 1978, the country has had a decentralized basic primary healthcare system, instead focusing on a district healthcare system run by local governments. Disparities exist between municipalities, depending on the funding from the local area. Poor municipalities with little funding have little allocated for their healthcare budgets. Rural areas are poorly funded as compared to urban areas. Poor women, especially in rural areas, are often seen by a nurse or nurse–midwife for prenatal care and delivery, whereas urban women more often receive prenatal care and delivery from a physician (Harrison, 2004).
The South African healthcare system faces many challenges. The country’s history of very high rates of communicable and noncommunicable diseases, combined with the legacy of colonialism, Apartheid, and post-Apartheid turmoil, have led to major racial and gender discrimination, a migrant labor system, destruction of family life, great disparities in family incomes, and extreme violence, which have all affected the health and healthcare system of the nation. For many decades, black people were forced to work for the white minority for very low wages. Before 1994, politics restricted health and healthcare for blacks. The public healthcare system has now been transformed into an integrated national service, but is plagued by a lack of management and leadership. Some of the main problems related to health include poverty-related illnesses such as infectious diseases (HIV/AIDS, TB, and malaria), maternal mortality, malnutrition, and high rates of noncommunicable diseases. HIV/AIDS accounts for 31% of the disability-adjusted life-years, and violence and injury continue to cause premature deaths (Coovadia et al., 2009).
South Africa is considered a middle-income country because of its economy, yet its disease rates are higher than those in many low-income countries. It is one of only 12 countries in the world where child mortality has increased, rather than decreased, since the 1990 Millennium Developmental Goals were established (Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009). There are great disparities between the country’s public and private healthcare systems. Less than 15% of the population uses private health care, yet 46% of all healthcare expenditures are devoted to private healthcare services. There is also a disparity in funding among the provinces within South Africa’s healthcare system.
State of Health in South Africa
The general state of health in South Africa reflects the huge burden of disease, particularly the tremendous impact of HIV/AIDS. HIV rates have reached as high as 31% of all pregnant women being HIV positive, and 25% of the general population being HIV positive. Approximately 5 million people in South Africa are living with HIV/AIDS at present. The link between high risk sexual behaviors, IV drug use, and transfer of HIV virus from mother to child (vertical transmission) which resulted in HIV disease was long denied by both former president Thabo Mbeki and former Prime Minister Kgalema Motlanthe. In 2008, Mbeki resigned, and by 2009 a new government administration was committed to increasing the funding for HIV/AIDS treatment. Only 12% to 13% of patients who need antiretroviral drugs actually receive them, however. Approximately 60% to 70% of all hospital admissions are HIV/AIDS related, which is creating a huge burden on the healthcare system, with concomitant challenges related to financing of health care and availability of trained healthcare personnel. At present there are 1.2 million orphans in South Africa, In addition, many elderly have lost their financial support due to the early deaths of their adult children from HIV/AIDS (Coovadia et al., 2009).
Violence and Injury
South Africa also has many disturbing social issues that have proved challenging to manage. It is estimated that 500,000 women are raped each year in the country. Approximately 28% of men state that they have committed rape. Gender-based violence is especially high, with South African female homicide rates being six times the global average; 50% of the female victims are killed by their spouses or partners. In addition, this country is ranked by the United Nations as second in the world for murder and first for assaults and rape. Violence and injury are the second leading cause of death, and the injury rate is almost twice the global average. Approximately 16,000 road-related (motor vehicle collision) deaths occur yearly. Children also are subject to very high rates of sexual, physical, and emotional abuse and neglect (Coovadia et al., 2009).
Maternal and Infant Health
South Africa has a major problem with maternal and infant health. The infant mortality rate is 42.5 per 1000 live births. Each year approximately 75,000 children die, and 23 die within their first month of life. In addition, 23,000 babies are stillborn, a factor closely associated with the 1660 maternal deaths that occur annually. The major causes of maternal deaths are HIV/AIDS infections. Strengthening HIV/AIDS health care will require at least a 2.4% increase in funding for HIV prevention and treatment programs (Coovadia et al., 2009).
Major Health Issues
As noted previously, South Africa is challenged by very high rates of injury, the problem of underdevelopment of the country as a whole, and numerous residents with chronic diseases. The largest rise in death rates for adults has occurred among the young adult group, who are dying in increasing numbers from HIV/AIDS. Deaths from tuberculosis, pneumonia, and diarrhea are also increasing rapidly. The leading cause of death in South Africa is HIV/AIDS (infants and young adults), followed by homicide (young adult men), tuberculosis, road traffic accidents, and diarrhea. Large numbers of deaths from noncommunicable diseases occur in the 60 and older group of the population. Causes of death for children younger than 5 years are ranked as follows (Bradshaw & Nannan, 2004):
1. HIV/AIDS
2. Low birth weight
3. Diarrhea
4. Lower respiratory infections
5. Protein-energy malnutrition
6. Neonatal infections
7. Birth asphyxia and birth trauma
8. Congenital heart disease
9. Road traffic accidents
10. Bacterial meningitis
There is a significant increase in the use of tobacco in South Africa, which in turn is causing more lung diseases, especially lung cancer. Campaigns to deter youth from smoking and encourage smokers to stop are being led by healthcare organizations in increasing numbers.
Throughout South Africa, there is a major change in diet in terms of types and quantity of foods consumed, with movement away from traditional plant foods to high-fat and high-sugar foods with low fiber. As a result of this change, overweight and obesity are now chronic problems among South African people. Urban people are more likely to be obese than rural people, and those older than 65 years are less likely to be obese. South Africans are now more sedentary than they previously were as well.
Alcohol consumption is also increasing, especially among males. It not only is causing chronic diseases such as liver and esophageal cancer, but also is contributing to homicides, violence, and motor vehicle accidents (Bradshaw & Nannan, 2004).
Racial/ethnic Inequalities
Numerous racial inequalities continue to exist in the wake of Apartheid. Significant disparities in standards of living persist, with most blacks continuing to lack adequate public health services, such as clean water, a proper sewage system, and access to health care, making them much more vulnerable to disease. Unemployment is much higher within the black or African populations compared to the other ethnic groups. Whites are the most employed group. Half of all Africans live in formal housing (solid structures with indoor plumbing and electricity), compared with 95% of whites. Poverty-related health problems such as infectious diseases, maternal and infant deaths, and malnutrition remain widespread (Kon & Lackan, 2008).
Healthcare Personnel
There is a shortage of nursing and other healthcare personnel in South Africa, as well as a problem of maldistribution of resources. The majority of trained nursing and allied health professionals work in the private sector, which serves much less of the general population than does the public sector. In addition, more trained health personnel work in urban areas than in rural areas. Doctors, especially those with more subspecialty training, are more likely to work in the private sector and in urban areas (79%) as well. Moreover, there has been a trend of skilled health personnel leaving South Africa for other countries, such as the United States, Canada, New Zealand, the United Kingdom, and Australia. South Africa is actively trying to recruit nurses and doctors, especially to work in the underserved areas. In addition to healthcare personnel trained in Western medicine, there are 200,000 traditional healers who practice in South Africa (Coovadia et al., 2009; Padarath, Ntuli, & Berthiaume, 2004).
Chronic Diseases
South Africa, a developing country, currently is experiencing a vast increase in the prevalence of chronic diseases, which historically were more associated with developed countries. Health problems such as hypertension, elevated cholesterol, alcohol and tobacco use, and obesity are now being observed in South Africa in greater frequencies. Risks for chronic diseases reflect individuals’ age, gender, tobacco and alcohol use, diet, and physical activity. Other risk factors include family history and genetic background. Most chronic diseases are preventable with modification of lifestyle behaviors, and changes in activity and diet can greatly influence the risk for numerous chronic diseases.
The leading causes of deaths in South Africa include the following:
■ HIV/AIDS
■ Heart disease
■ Homicide and violence
■ Stroke
■ Tuberculosis
■ Lower respiratory infections
■ Road traffic accidents
■ Diarrhea diseases
■ Hypertension
■ Diabetes
All of these conditions are chronic diseases, with the exception of homicide and violence and traffic accidents (Coovadia et al., 2009; Padarath, Ntuli, & Berthiaume, 2004).
Communicable Diseases
Sexually transmitted infections (STIs) remain one of the most common problems in adolescents and young adults in South Africa. Approximately 10% of all adults who visit a health clinic have concerns about a STI. Nearly 4 million people develop these diseases each year. Healthcare workers are involved in treatments and prevention measures, such as counseling, condom promotion, and partner notification (Shabalala et al., 2002).
Tuberculosis is a chronic pulmonary and extrapulmonary disease characterized by positive acid-fast stains or cultures of Mycobacterium tuberculosis. A TB skin test provides evidence of the infection, if positive. A chest X-ray is taken to confirm shadowing, reflecting lung invasions from TB. Cervical lymph node swelling may also be present.
Tuberculosis is a huge problem in South Africa. South Africa ranks fifth in the world in number of TB cases, with 948 cases per 100,000 population, and cure rates remain at 60%. Part of the reason for the high prevalence in this country is improved case detection brought on by the HIV/AIDS epidemic, especially among young adults. The high rate also reflects South Africa’s poor standard of living, which is characterized by poverty and overcrowding. Other factors include the increase and extent of drug resistance, particularly multidrug resistance (MDR) (Mwinga & Fourie, 2004). A recent study reported that 55% of the people with TB were also HIV positive. Those affected by HIV/AIDS are five times more likely to develop TB. One-third of the 40 million people in all of Africa with HIV/AIDS also have TB; in sub-Saharan Africa, the rate is even higher. The South African Medical Research Council predicted that there would be 300,000 cases of TB and 30,000 deaths from this cause in the country—a fatality rate of 10%, in a nation that once had one of the lowest TB death rates in Africa before the advent of HIV/AIDS (Bamford, Loveday, & Verkuijl, 2004; Nullis-Kapp, 2005). The Eastern Cape, a very poor rural area with limited resources, has an extremely high incidence of TB, with 675 cases per 100,000 population (Bamford et al., 2004).
Cholera is an intestinal illness caused by the Vibrio cholerae organism. Cholera results in loss of large volumes of watery stool (excrement), leading to rapid dehydration and shock, and often resulting in death without treatment. The fatality rate for untreated cholera is 50%. Persons with cholera develop rapid breathing, vomiting, and painless diarrhea, and they go into metabolic acidosis. Appropriate oral or intravenous rehydration therapy is needed to replace lost fluids and electrolytes.
Cholera is one of the diseases requiring notification of the WHO. Nevertheless, cholera epidemics remain common in Asia, Africa, India, and South America (Sack, Sack, Nair, & Siddique, 2005). In South Africa, cholera represents a significant burden. In 2000–2001, a cholera epidemic occurred, with 106,389 reported cases. Cholera deaths result from poor sanitation and poor-quality water supplies—and an estimated 18 million South Africans have no basic sanitation. Of this group, 75.8% live in rural areas. Almost 50% of those children go to schools where there is only a pit for toilet use. By 2002, after initiatives were undertaken to help those persons without water and sanitation, the number of persons in South Africa with cholera infection was reduced to 7 million (Duse, da Silva, & Zeitsman, 2003; Mudzanani, RatsakaMathokoa, Mahlasela, Netshidzivhani, & Mugero, 2004).
Across the continent of Africa, more than 38% of all people have no access to safe water—a percentage higher than that found in any other place in the world. In South Africa, some 12 million people lack safe water and 20 million lack sanitation facilities. By the year 2020, South Africa’s population demands will exceed its water supply by 6%. Health maintenance is dependent on an adequate water supply and adequate sanitation facilities (toilets). It is vital in hospitals and healthcare clinics to have adequate clean water and sanitation for prevention and treatment of diseases and illnesses. A clean and adequate supply is necessary for simple hand washing in patient care. In short supply areas, it is necessary for health-care workers to disinfect water if unclean and teach similar techniques to patients. Example techniques include boiling, use of chlorine tablets, filtration, and clean storage (Duse et al., 2003).
Malaria is a serious disease transmitted to humans by the bite of the Anopheles mosquito. Symptoms include fever and a flulike illness characterized by chills, headache, muscle aches, and fatigue. Malaria can also cause anemia and jaundice. If not treated promptly, this infection can lead to kidney failure, coma, and death. Malaria can be prevented by antimalarial drugs, such as atovaquone/proguanil, doxycycline, and mefloquine. Chloroquine is not effective for malaria prevention in South Africa. Protection from mosquito bites is also very important (Centers for Disease Control and Prevention [CDC], 2004).
Malaria is a major health problem in sub-Saharan Africa and affects great numbers of young children and pregnant women. It is the main cause of 20% of all deaths of young children in Africa. Approximately 95% of the infections in South Africa are due to Plasmodium falciparum, a microbe that lives in the gut of the Anopheles mosquito. Transmission is seasonal, with October to February seeing the emergence of the largest number of cases. Use of drugs for treatment and vector control by spraying has proved effective in deterring infection. South Africa, along with five other countries, was given permission by the United Nations Environmental Programme to use DDT for public health use only. The application of DDT in 2000 led to significant improvements in the mortality and morbidity associated with this disease. It should be noted, however, that DDT is a banned pesticide in the United States and most developed and developing countries (Moonasar et al., 2004).
South Africa has an estimated 4–6 million people living with HIV/AIDS. The national prevalence of HIV in pregnant women is 26.2%. A study by the South African Medical Research Council concluded that for 2000–2001, the prevalence of HIV/AIDS was almost three times as high in reality as that listed in a government statistical report. In 80% of AIDS-related deaths in men, and 70% in women, the cause of death listed on the death certificate as TB or lower respiratory tract infection. In children, three times as many AIDS-related deaths were identified as due to lower respiratory tract infections, diarrheal disease, and protein-energy malnutrition, rather than AIDS (“South Africa Needs to Face the Truth,” 2005).
The highest rates of disease transmission occur among newborns and breastfed children. Poverty increases the vulnerability to HIV infection somewhat, because poor people usually have less education and less access to information about safe sex practices. High unemployment rates and lack of support may deny mothers access to care in clinics. Access to antiretroviral therapy (ART) drugs for HIV/AIDS patients in South Africa is very limited. In 2002, of the 500,000 who could immediately benefit from such medications, only 20,000 to 40,000 were receiving treatment; of those who were receiving treatment, most were receiving care in the private sector. In 2003, the government made ART more widely available to the public sector. One problem in providing these drugs is the very high costs for the medications and tests (Doherty & Colvin, 2004).
In 2005 in South Africa, where less than 3% of people who need ART actually receive it, private companies began supplying drugs directly to employees who are HIV positive. The corporate sector is presently taking more responsibility for care of workers with this disease than ever before (Venter, 2005).
Some of the social factors that make South African women vulnerable to HIV/AIDS relate to the position of women in society and practice of safe sex. Women are often born into a low social status in South Africa. Physiologically men are able to pass the virus to women more easily than women pass the virus to men, making a woman twice as likely to become infected. Women are also vulnerable to contracting the HIV virus and many other STIs because of the greater mucosal surface exposed to pathogens in females during sexual activity, particularly in young girls, who are not fully mature.
Another HIV/AIDS risk factor is the very high rate of violence against women in South Africa. The incidence of rape in South Africa is considered to be among the highest in the world, yet these crimes are seldom reported. Rates of rapes of female children are exceptionally high. A myth that “having sex with a virgin will cure AIDS” remains to blame for part of the increase in child rape. In addition, a very high incidence of husband/boyfriend violence occurs. Women can be beaten if they refuse to have sex with their partners. Women often remain in abusive relationships for financial dependency reasons. No matter why it occurs, violence against women increases the risk of HIV and STI infections.
In South Africa, 30% of women are heads of households; these individuals are often poor, have no financial aid from men, and consequently have a very unfavorable economic position and little power. Selling sex can often be a survival strategy for these women, albeit one that makes them even more vulnerable to HIV. Young girls may trade sex for money, clothes, or food (Ackerman & de Klerk, 2001).
Another problem in South Africa is the increasing number of orphans who are left behind when both of their parents die of AIDS. Some grandparents are trying to provide care for as many as 10 to 20 grandchildren after they have lost their children. Other AIDS orphans are left alone to care for themselves. There is a lost generation of street children who have no education and have few economic resources. Some sell themselves for sex to keep themselves and siblings fed. Some are HIV infected and some are not, but many will die regardless of their situation (Sowell, 2000).
Aging
The South African population is aging because of declining fertility rates and decreases in life expectancy among those persons infected with HIV. In 2001 those in their 70s represented 3.2% of the population, and those in their 80s represented 1%. Elderly adults are expected to account for 30 people per 100 population in 2015. Even with the AIDS epidemic there will be a large number of adults 65 and older, as compared to the number of children—AIDS affects the older adult population to the least extent (Joubert & Bradshaw, 2004).
The older black adults of South Africa are among the poorest people in the country and often lack credit or employment. Most have lived through the Apartheid years and have been poor all their lives. Fifty-eight percent of older adult Africans have no education; in Limpopa the rate is 74%, and in Mpurmalanga the rate is 66%. Many older adults, especially the Africans who live in poverty and have little or no formal education, are now taking care of their children and/or grandchildren, which is a very difficult burden. Their main source of income is Social Protection (Old Age Pension), which is provided for men 65 and older and for women 60 and older (Joubert & Bradshaw, 2004).
Traditional Medicine
The Alma-Ata Declaration on primary health care, in conjunction with WHO and the United Nations International Children’s Emergency Fund (UNICEF), gave international recognition to the positive role of traditional indigenous healthcare providers. Traditional practitioners and birth attendants are recognized as important people in the primary healthcare team, but not as part of the public health service. Historically Western-style health practitioners, such as Dr. David Livingston, consulted with indigenous healers on drug treatment for fevers. Within South Africa, many traditional healers believe that illness cannot be directly explained in physical terms, and some believe in supernatural entities, such as spirits, that bring about illness. Some also believe in direct causal connections comparable to Western medicine. Different healthcare ideologies and systems have stood side by side together in South Africa for many years. Patients may want to use both types of medicine “just to play it safe.” As many as 80% of the indigenous African people are accustomed to using traditional medicine as a first means for treatment of illness. Their faith in this system may not necessarily be misplaced: Noristan Laboratories, a large pharmaceutical company, tested 350 herbs used by indigenous healers and found that 80% had some medicinal properties. In any event, patients are faced with two healthcare system perspectives and will most likely continue to seek care from either as they see fit. At present, there is limited cooperation between the two systems (Muller & Steyn, 1999).
The indigenous flora of South Africa include 23,404 higher plant species, and the use of many of these species for medicinal use dates back to the San people in the region more than 20,000 years ago. Traditional medicine use in South Africa is often unacknowledged by the Western-style healthcare system, yet pharmacists are often well equipped to bridge the gap between indigenous medicines and Western ones (Scott, Springfield, & Coldrey, 2004).
CONCLUSION
Table 3-18 compares and contrasts a variety of health statistics for the developing countries covered in this chapter—Egypt, China, India, and South Africa. It identifies the health indicator or type of health issue, the date of data collection, data type, and then the various data collected from each country.
This chapter has addressed the health and health care of four developing countries. Although Egypt, China, India, and South Africa are located in different regions of the world, and they have a variety of languages, customs, values, health practices, types of government, and health care per capita allocations, they also share some commonalities and similar health challenges. Although the data presented here can be used for cross-country comparisons, the definitions of health problems and data collection methodology may greatly differ, so that these comparisons, at best, may be only a good estimate for a certain time and geographical location.
TABLE 3-18 Healthcare Statistics for Egypt, China, India, and South Africa
Data
Indicator
Date/Date Range
Data Type
China
Egypt
India
South Africa
HIV/AIDS
People living with HIV/AIDS
Data from most recent year available
Number
740,000
11,000
2,400,000
5,600,000
Adults living with HIV/AIDS
2009
Number
730,000
10,000
2,300,000
5,300,000
Adult HIV/AIDS prevalence rate
2009
%
0.1%
<0.1%
0.3%
17.8%
Women living with HIV/AIDS
Number of women living with HIV/AIDS and women as a percentage of adults living with HIV/AIDS, 2009
%
32%
24%
38%
62%
Men living with HIV/AIDS
Number of men living with HIV/AIDS and men as a percentage of adults living with HIV/AIDS, 2009
%
NA
81%
61%
38%
Children living with HIV/AIDS
2009
Number
NA
NA
NA
330,000
AIDS deaths
2009
Number
26,000
<500
170,000
310,000
AIDS orphans
2009
Number
NA
NA
NA
1,900,000
ARV need
2009
Number
NA
3,300
NA
2,600,000
ARV treatment
2009
Number
65,481
359
320,074
971,556
ARV coverage Rate
2009
%
NA
11%
NA
37%
Tuberculosis
Tuberculosis HBCs
2010
Text
Yes
No
Yes
Yes
New TB cases
2009
Number
1,300,000
15,000
2,000,000
490,000
New TB smear-positive cases
2008
Number
640,000
6500
890,000
200,000
New TB case rate
2009
Rate per 100,000
96
19
168
971
People living with TB
2009
Number
1,900,000
25,000
3,000,000
400,000
TB prevalence rate
2009
Rate per 100,000
138
30
249
808
TB death rate
2009
Rate per 100,000
12
1
23
52
TB prevalence in HIV-positive people per 100,000 population
2007
Rate per 100,000
1
0
4
345
Malaria
Malaria cases
2009
Number
14,491
94
1,563,344
6072
Malaria deaths
2009
Number
12
2
1133
45
Other Diseases, Conditions, and Risk Indicators
Yellow fever cases
2009
Number
NA
NA
NA
0
Yellow fever deaths
2004
Number
0
0
0
0
Diphtheria cases
2009
Number
0
0
NA
1
Measles cases
2009
Number
52,461
608
NA
5857
Polio cases
2009
Number
0
0
752
0
DTP3 immunization coverage rate
2009
%
97%
97%
66%
69%
Vitamin A supplementation coverage rate
2009
%
NA
NA
66%
NA
Percentage with water
2008
%
89%
99%
88%
91%
Access to sanitation
2008
%
55%
94%
31%
77%
Population undernourished
2005–2007
%
10%
NA
21%
NA
Low-birth-weight babies
2000–2009
%
3%
13%
28%
NA
Child malnutrition
2000–2009
%
6.8%
6.8%
43.5%
NA
Female prevalence of obesity
2005
%
2%
46%
1%
35%
Male prevalence of obesity
2005
%
2%
22%
1%
7%
Female prevalence of smoking
2006
%
4%
1%
4%
9%
Male prevalence of smoking
2006
%
59.5%
27.6%
33.2%
29.5%
Programs, Funding, and Financing
Financial development assistance for health per capita
2007
U.S. dollars
$0.18
$1.23
$0.50
$6.60
USAID NTD program countries
Fiscal year 2010
Text
No
No
Yes
No
USAID maternal assistance
Fiscal year 2010
Text
No
Yes
Yes
No
U.S. food assistance program countries
Fiscal year 2008
Text
No
No
Non-emergency
No
USAID nutrition program countries
Fiscal year 2010
Text
No
Yes
Yes
No
Health expenditure per capita
2008
U.S. dollars
$265
$261
$122
$843
Total expenditure on health
2008
%
4.3%
4.8%
4.2%
8.2%
Government health expenditures as a percentage of total government expenditures
2008
%
10.3%
5.9%
4.4%
10.4%
Government health expenditures as a percentage of total health expenditures
2008
%
47.3%
42.2%
32.4%
39.7%
Social security expenditures on health
2008
%
66.3%
21.6%
17.2%
3.0%
Out-of-pocket expenditures on health
2008
%
82.6%
97.7%
74.4%
29.7%
Health Workforce and Capacity
Physicians
2000–2010
Rate per 10,000
14
28
6
8
Nurses and midwives
2000–2010
Rate per 10,000
14
35
13
41
Community health workers
2000–2010
Rate per 10,000
8
NA
1
NA
Births attended by skilled health personnel
2000–2010
%
96%
79%
47%
91%
Hospital beds
2000–2009
Rate per 10,000
30
21
9
28
Demography and Population
Population
2011
Number
1,336,718,015
82,079,636
1,189,172,906
49,004,031
Adult sex ratio
2011
Number
1.17
1.03
1.07
1.02
Median age
2011
Number
35.5
24.3
26.2
25.0
Population younger than age 15
2010
%
18%
33%
32%
31%
Urban population
2010
%
47%
43%
29%
52%
Land area
2009
Number
9,560,981
1,001,449
3,287,263
1,221,037
Population density
2010
Number
140
80
362
41
Birth rate
2011
Rate per 1000
12.29
24.63
20.97
19.48
Total fertility rate
2011
Number
1.54
2.97
2.62
2.30
Adolescent fertility rate
2000–2008
Rate per 1000
5
50
45
54
Contraceptive prevalence rate
2000–2010
%
84.6%
60.3%
56.3%
59.9%
Death rate
2011
Rate per 1000
7.03
4.82
7.48
17.09
Infant mortality rate
2011
Rate per
1000
16.06
25.20
47.57
43.20
Female infant mortality rate
2011
Rate per 1000
16.57
23.52
49.14
39.14
Male infant mortality rate
2011
Rate per 1000
15.61
26.80
46.18
47.19
Under-five mortality rate
2009
Rate per 1000
19
21
66
62
Maternal mortality ratio
2008
Rate per 100,000
38
82
230
410
Life expectancy: female
2009
Number
76
73
66
55
Life expectancy: male
2009
Number
72
69
63
54
Population growth rate
2011
%
0.49%
1.96%
1.34%
-0.38%
Income and the Economy
GDP per capita
2009
$
$6828
$5673
$3296
$10,278
GNI per capita
2009
$
$6890
$5680
$3280
$10,050
Population living on less than $1.25 per day
Data from most recent year available
%
4.0% (2005)
0.4% (2005)
10.5% (2005)
3.3% (2006)
Unemployment rate
Data from most recent year available
%
4.3% (2005)
9.7% (2010)
10.8% (2010)
23.3% (2010)
Country income classification
As of July 2011
Text
Upper middle income
Lower middle income
Lower middle income
Upper middle income
External country debt
2009
U.S. dollars
$428,442
$33,257
$237,692
$42,101
ARV: ntiretroviral therapy.
Source: Kaiser Family Foundation, n.d.
STUDY QUESTIONS
1. How are the health issues of infant mortality and nutrition similar for the countries of Egypt, China, India, and South Africa?
2. Compare and contrast the health beliefs and practices of traditional medicine in China with those in India. How do cultural influences affect health and health care differently? What are some basic commonalities?
3. What are some contributory factors leading to the exceptionally high rate of HIV/AIDS in South Africa?
CASE STUDY
Smoking And Health Concerns Vs. Tobacco Production In China
“As the health impact of smoking, including rising heart disease and lung cancer, gradually emerges, unless there is effective government intervention, it will affect China’s overall economic growth due to lost productivity,” said Yang Gonghuan, deputy director of the Chinese Center for Disease Control and Prevention. Lost productivity from smoking-related health problems will hamper China’s economic growth, and related costs incurred by smoking far exceed the tobacco industry’s contribution in terms of profits and jobs it generates. China’s addiction to huge revenues from the state-owned tobacco monopoly is hindering anti-smoking measures, potentially costing millions of lives in the country with the world’s largest number of smokers. The warnings, issued in a report prepared by a group of prominent public health experts and economists, came amid growing calls for the government to give stronger support to tobacco-control measures. China is the world’s largest tobacco producing and consuming country, with more than 300 million smokers on the mainland. Each year, about 1.2 million people die from smoking-related diseases on the mainland and the figure will increase to 3.5 million by 2030, according to estimates from the World Health Organization (WHO). The report underscores increasing concern that the country’s economic potential will be jeopardized due to escalating medical costs and lost productivity if the government fails to take serious action to combat smoking.
Reference
Shan, J. (2012). Report: Smoking industry harming economic health. China Daily.
Case Study Questions
1. What are some major health risks related to smoking and what is the impact on health for the Chinese people?
2. Why do you think that government owned tobacco production in China continues in spite of knowledge about health risks?
3. How would you suggest that smoking in China be decreased?
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